Combined uphill and downhill varices as a consequence of rheumatic heart disease: a unique presentation.

Hemorrhage from downhill varices is a rare manifestation. The etiology of downhill varices is due to superior vena cava obstruction while uphill varices are secondary to portal hypertension. We report a rare case of 55-year-old female with bleeding downhill varices not associated with obstruction or compression of superior vena cava, but was due to severe pulmonary artery hypertension secondary to chronic rheumatic heart disease.